Branches of the abdominal aorta. Embolism of the superior mesenteric artery The superior mesenteric artery is a branch

The superior and inferior mesenteric arteries are responsible for supplying blood to certain organs and arise from the main aorta. They have many branches, spreading to different parts of the intestines, stomach and kidneys. Disturbances in the mesenteric arteries lead to lack of nutrition, which leads to the development of diseases.

Structure of the superior mesenteric vessel

A large vessel forms in the anterior part of the aorta. The origin of the superior mesenteric artery is 1-3 cm under the celiac trunk. It goes behind the pancreas, from where it goes down to the right. Next to it - on the right side - is the mesenteric vein. Together they run along the first wall of the duodenum horizontally and transversely, moving to the right side from the jejunal fracture.

Next, the blood element reaches the root of the mesentery and passes between the layers of the small intestine, creating an arch convex to the left. Thus, it passes to the right iliac fossa and is divided into several branches. Arteries arise from it:

Lower pancreaticoduodenal. It begins at the starting point of the blood vessel and is divided into anterior and posterior parts. They go down and pass along the anterior wall of the pancreas, bypassing the head at the junction with the intestine. Small branches extend to the gland and duodenum, and then diverge from the upper pancreaticoduodenal blood elements.
Jejunal. In total, there are from 7 to 8 of them in the human body, and the blood vessels depart one after another from the convex zone. They are directed through the leaves of the mesentery to the jejunum. Each branch of the mesenteric artery is further divided into 2 trunks and intertwined with the vessels of the intestinal branches.
Ileo-intestinal. They extend to the loops of the ileum. There are 5-6 of them in the body. Like the previous ones, the iliac blood elements are divided into 2 trunks and form arcs of the 2nd order (small size). Even smaller arteries branch off from them again and go to the walls of the loops of the small intestine. They also form small branches responsible for feeding the lymph nodes of the mesenteric region.
Ileocolic. It begins in the area of the cranial part of the mesenteric vessel and goes to the right side to the ileum along the posterior wall of the abdominal cavity. It is divided into additional branches that extend to the cecum and colon, as well as to the area of the ileum.
Right colon—intestinal. Forms a process on the right side of the main mesenteric artery, starting from the upper third. Goes to the edge of the colon.
Average colon—intestinal. It originates in the upper part of the mesenteric artery, passes through the mesentery of the colon and divides into 2 branches. The right one goes to the ascending vessel, and the left one forms a branch through the mesenteric edge of the intestine.

Several large branches are separated from the ileocolic vessel. The first is the ascending artery, which departs from the right to the colon and rises to the blood branch emanating from this area. There it forms an arch from which the colic branches are formed. They are responsible for supplying blood to the upper part of the cecum and the ascending colon.

From the same blood branch, the cecal arteries extend forward and backward, heading to the cecum. They form a vascular network extending to the ileocecal angle, where they connect with the terminal arteries of the ileal arch.

Another feeding element is the appendix, which is responsible for the blood supply to this area. These arteries pass through the mesentery of the appendix.

The superior mesenteric artery is not a separate blood vessel, but a whole system of descending branches with a slope to the right side.

The structure of the inferior mesenteric branch

The lower section of the mesenteric vessel is located at the edge of the third vertebra, just above the division of the aorta. It descends down to the left and is located behind the abdominal wall on the surface of the psoas muscle. The anatomy of the inferior mesenteric artery has several branches:

colica constanta – ascending and descending pair;
sigmoideae - with several branches forming an arch;
rectalis superior - descends into the mesentery of the sigmoid colon and goes into the small pelvis, forming several lateral branches to the rectum.

The formation of vessels from these arteries forms anastomoses along the entire length of the rectum.

Basic functions

The superior and inferior mesenteric arteries are part of the circulatory system. Since these are quite large vessels, they are considered the main sources of nutrition for the abdominal organs, including all branches. The superior artery supplies blood to more than half of the intestines, as well as the entire pancreas.

Dysfunction of the superior mesenteric vessel leads to a general deterioration in blood circulation. Because of this, internal organs located in the peritoneum suffer, most often the large intestine.

Embolism of the circulatory mesentery

Common superior artery disease begins with acute abdominal pain located in the periumbilical area. In some patients, symptoms begin in the lower right abdomen. The intensity of pain depends on many factors and can vary greatly.

Upon palpation, the doctor detects that the abdomen is too soft, as well as a slight tension in the muscles of the anterior wall. There is virtually no pain during the examination. In some cases, increased intestinal motility is observed.

Patients with embolism often suffer from vomiting, nausea and diarrhea. In this case, no functional disorders are detected during the examination. In the early stages, occult blood is detected in stool tests, but there are no visible impurities.

The presence of embolism can be suspected by a combination of symptoms from the gastrointestinal tract, as well as the cardiovascular system. Often, embolism develops in people who have recently had a heart attack or have rheumatic valve lesions.

Features of treatment

Therapy for embolism is possible using conservative methods, but in the acute course of the disease, the best results are observed only after surgical intervention. The laparotomy method is used, in which the superior artery is opened and an embolectomy is performed.

As a result of the operation, blood flow is restored, and the condition of the small intestine is determined. Sometimes during the procedure, necrosis of part of the tissue of this part of the intestine is detected. Then, during surgery, doctors remove the damaged cells. After surgery, an additional autopsy is scheduled 24 hours later to ensure the viability of the intestine.

A. mesenterica superior, superior mesenteric artery, departs from the anterior surface of the aorta immediately below the vermiform trunk, goes down and forward, into the gap between the lower edge of the pancreas in front and the horizontal part of the duodenum behind, enters the mesentery of the small intestine and descends to the right iliac fossa .

Branches, a. mesentericae superioris:

a) a. pancreatieoduodeiialis inferior goes to the right along the concave side of the duodeni towards aa. pancreaticoduodenales superiores;

b) aa. intestinales of branches that extend from a. mesenterica superior to the left side to the jejunum (aa. jejundles) and ileum (aa. ilei) intestine; along the way they are divided dichotomously and adjacent branches are connected to each other, which is why it turns out along aa. jejunales three rows of arcs, and along aa. ilei - two rows. The arches are a functional device that ensures blood flow to the intestines with any movements and positions of its loops. Many thin branches extend from the arches, which encircle the intestinal tube in a ring;

c) a. ileocolica extends from a.r mesenterica superior to the right, supplying the lower portion of the intestinum ileum and the cecum with branches and sending them to the vermiform appendix a. appendicularis, passing behind the final segment of the ileum;

d) a. colica dextra goes behind the peritoneum to the colon ascendens and near it is divided into two branches: ascending (goes upward to meet a. colica media) and descending (descends to meet a. ileocolica); branches extend from the resulting arches to the adjacent parts of the colon;

e) a. Colica media passes between the leaves of the mesocolon transversum and, having reached the transverse colon, is divided into right and left branches, which diverge in the corresponding directions and anastomose: the right branch - with a. colica dextra, left - with a. colica sinistra

Inferior mesenteric artery (a. mesenterica inferior).

A. mesenterica inferior, the inferior mesenteric artery, departs at the level of the lower edge of the third lumbar vertebra (one vertebra above the division of the aorta) and goes down and slightly to the left, located behind the peritoneum on the anterior surface of the left lumbar muscle.

Branches of the inferior mesenteric artery:

a) a. colica sinistra is divided into two branches: the ascending one, which goes towards the flexura coli sinistra towards a. colica media (from a. mesenterica superior), and descending, which connects to aa. sigmoideae;

b) aa. sigmoideae, usually two to the colon sigmoideum, with ascending branches anastomose with the branches of a. colica sinistra, descending - with

c) a. rectalis superior. The latter is a continuation of a. mesenterica inferior, descends at the root of the mesentery colon sigmoideum into the small pelvis, crossing a. iliaca communis sinistra, and splits into lateral branches towards the rectum, which enter into connection with both aa. sigmoideae, as well as with a. rectalis media (from a. iliaca interna).

Thanks to the interconnection of the branches of aa. colicae dextra, media et sinistra and aa. rectales from a. iliaca interna the large intestine along its entire length is accompanied by a continuous chain of anastomoses connected to each other.

Paired visceral branches: renal artery (a. renalis), middle adrenal artery (a. suprarenalis media).

Paired visceral branches depart in the order of arrangement of organs determined by their anlage.

1. A. suprarenalis media, middle adrenal artery, starts from the aorta near the beginning of a. mesenterica superior and goes to gl. suprarenalis.

2. A. renalis, the renal artery, departs from the aorta at the level of the II lumbar vertebra almost at a right angle and goes in a transverse direction to the gate of the corresponding kidney. The caliber of the renal artery is almost equal to the superior mesenteric artery, which is explained by the urinary function of the kidney, which requires a large blood flow. The renal artery sometimes departs from the aorta in two or three trunks and often enters the kidney with multiple trunks, not only in the hilum area, but along the entire medial edge, which is important to consider when preliminary ligation of the arteries during kidney removal surgery. At the hilum of the kidney a. renalis is usually divided into three branches, which in the renal sinus in turn break up into numerous branches (see “Kidney”).

The right renal artery lies behind v. cava inferior, head of the pancreas and pars descendens duodeni, left - behind the pancreas. V. renalis is located in front and slightly below the artery. From a. renalis extend upward to the lower part of the adrenal gland a. suprarenalis inferior, as well as a branch to the ureter.

3. A. testucularis (in women a. ovarica) is a thin long stem that starts from the aorta immediately below the beginning of a. renalis, sometimes from this last one. Such a high origin of the artery supplying the testicle is caused by its origin in the lumbar region, where a. testicularis occurs at the shortest distance from the aorta. Later, when the testicle descends into the scrotum, a. testicularis, which at the time of birth descends along the anterior surface of m. psoas major, gives off a branch to the ureter, approaches the internal ring of the inguinal canal and, together with the ductus deferens, reaches the testicle, which is why it is called a. testicularis. The woman has the corresponding artery, a. ovarica, is not directed to the inguinal canal, but goes to the small pelvis and further as part of the lig. suspensorium ovarii to the ovary.

Parietal branches of the abdominal aorta: inferior phrenic artery (a. phrenica inferior), lumbar arteries (Aa. lumbales), median sacral artery (a. sacralis mediana).

1. A. phrenica inferior, the inferior phrenic artery, supplies blood to the pars lumbalis of the diaphragm. She gives a small twig, a. suprarenalis superior, to the adrenal gland.

2. Ah. lumbales, lumbar arteries, usually four on each side (the fifth sometimes arises from a. sacralis mediana), correspond to the segmental intercostal arteries of the thoracic region. They supply blood to the corresponding vertebrae, spinal cord, muscles and skin of the lumbar and abdominal areas.

3. A. sacralis mediana, the median sacral artery, unpaired, represents a developmentally delayed extension of the aorta (caudal aorta).

Superior mesenteric artery

Superior mesenteric artery, a. mesenterica superior (Fig. 771, 772, 773; see Fig. 767, 779), is a large vessel that starts from the anterior surface of the aorta, slightly below (1-3 cm) the celiac trunk, behind the pancreas.

Coming out from under the lower edge of the gland, the superior mesenteric artery goes down and to the right. Together with the superior mesenteric vein located to the right of it, it runs along the anterior surface of the horizontal (ascending) part of the duodenum, crosses it across immediately to the right of the duodenojejunal flexure. Having reached the root of the mesentery of the small intestine, the superior mesenteric artery penetrates between the leaves of the latter, forming an arch convex to the left, and reaches the right iliac fossa.

Along its course, the superior mesenteric artery gives off the following branches: to the small intestine (with the exception of the upper part of the duodenum), to the cecum with the vermiform appendix, ascending and partially to the transverse colon.

The following arteries arise from the superior mesenteric artery.

Inferior pancreaticoduodenal artery, a. pancreaticoduodenalis inferior (sometimes not single), originates from the right edge of the initial section of the superior mesenteric artery. Divides into the anterior branch, r. anterior, and posterior branch, r. posterior, which go down and to the right along the anterior surface of the pancreas, bend around its head along the border with the duodenum. Gives branches to the pancreas and duodenum; anastomoses with the anterior and posterior superior pancreatoduodenal arteries and with branches of a. gastroduodenalis.
Jejunal arteries, aa. jejunales, 7-8 in total, depart sequentially one after another from the convex part of the arch of the superior mesenteric artery, and are directed between the layers of the mesentery to the loops of the jejunum. On its way, each branch is divided into two trunks, which anastomose with the same trunks formed from the division of adjacent intestinal arteries (see Fig. 772, 773).
Ileointestinal arteries, aa. ileales, in the amount of 5-6, like the previous ones, are directed to the loops of the ileum and, dividing into two trunks, anastomose with adjacent intestinal arteries. Such anastomoses of intestinal arteries have the form of arcs. New branches extend from these arcs, which also divide, forming arcs of the second order (slightly smaller in size). From the arches of the second order, arteries again depart, which, dividing, form arches of the third order, etc. From the last, most distal row of arches, straight branches extend directly to the walls of the loops of the small intestine. In addition to intestinal loops, these arches give rise to small branches that supply blood to the mesenteric lymph nodes.
Ileocolic artery, a. ileocolica, arises from the cranial half of the superior mesenteric artery. Heading to the right and down under the parietal peritoneum of the posterior wall of the abdominal cavity to the end of the ileum and to the cecum, the artery divides into branches supplying blood to the cecum, the beginning of the colon and the terminal ileum.

A number of branches arise from the ileocolic artery:

the ascending artery goes to the right to the ascending colon, rises along its medial edge and anastomoses (forms an arch) with the right colon artery, a. Colica dextra. The colonic branches extend from this arch, rr. colici, supplying blood to the ascending colon and the upper part of the cecum;
the anterior and posterior cecal arteries, aa.cecales anterior et posterior, are directed to the corresponding surfaces of the cecum. Are a continuation of a. ileocolica, approach the ileocecal angle, where, connecting with the terminal branches of the ileo-intestinal arteries, they form an arch, from which branches extend to the cecum and to the terminal part of the ileum - ileo-intestinal branches, rr. ileales;
arteries of the appendix, aa. appendiculares, arise from the posterior caecum artery between the layers of the mesentery of the appendix; supply blood to the vermiform appendix.

Rice. 775. Arteries of the transverse colon.

5. Right colonic artery, a. colica dextra, departs from the right side of the superior mesenteric artery, in its upper third, at the level of the root of the mesentery of the transverse colon, and goes almost transversely to the right, to the medial edge of the ascending colon. Before reaching the ascending colon, it is divided into ascending and descending branches. The descending branch connects with branch a. ileocolica, and the ascending branch anastomoses with the right branch of a. Colica media. From the arches formed by these anastomoses, branches extend to the wall of the ascending colon, to the right flexure of the colon and to the transverse colon (see Fig. 775).

6. Middle colonic artery, a. colica media, departs from the initial section of the superior mesenteric artery, goes forward and to the right between the leaves of the mesentery of the transverse colon and is divided into two branches: right and left.

The right branch connects to the ascending branch a. colica dextra, and the left branch runs along the mesenteric edge of the transverse colon and anastomoses with the ascending branch of a. colica sinistra, which arises from the inferior mesenteric artery (see Fig. 771, 779, 805). Connecting in this way with the branches of neighboring arteries, the middle colonic artery forms arches. From the branches of these arches, arches of the second and third order are formed, which give direct branches to the walls of the transverse colon, to the right and left bends of the colon.

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Superior mesenteric artery

Branches supply blood to the jejunum and ileum superior mesenteric artery: ah. jejunales, ilei and ileocolica.

Superior mesenteric artery, a. mesenterica superior, with a diameter of about 9 mm, departs from the abdominal aorta at an acute angle at the level of the first lumbar vertebra, 1-2 cm below the celiac trunk. First it goes retroperitoneally behind the neck of the pancreas and the splenic vein.

Then it comes out from under the lower edge of the gland, crosses the pars horizontalis duodeni from top to bottom and enters the mesentery of the small intestine. Having entered the mesentery of the small intestine, the superior mesenteric artery runs through it from top to bottom from left to right, forming an arcuate bend, convexly directed to the left.

Here, branches for the small intestine extend from the superior mesenteric artery to the left, aa. jejunales et ileales. From the concave side of the bend, branches for the ascending and transverse colon extend to the right and upward - a. colica media and a. Colica dextra.

The superior mesenteric artery ends in the right iliac fossa with its terminal branch - a. ileocolica. The vein of the same name accompanies the artery, being to the right of it. A. ileocolica supplies the final section of the ileum and the initial section of the colon.

The loops of the small intestine are very mobile; waves of peristalsis pass through them, as a result of which the diameter of the same section of the intestine changes; food masses also change the volume of intestinal loops at different lengths. This, in turn, can lead to disruption of the blood supply to individual intestinal loops due to compression of one or another arterial branch.

As a result, a compensatory mechanism of collateral circulation has developed, maintaining normal blood supply to any part of the intestine. This mechanism works like this: each of the small intestinal arteries at a certain distance from its beginning (from 1 to 8 cm) is divided into two branches: ascending and descending. The ascending branch anastomoses with the descending branch of the overlying artery, and the descending branch anastomoses with the ascending branch of the underlying artery, forming arches (arcades) of the first order.

New branches extend from them distally (closer to the intestinal wall), which, bifurcating and connecting with each other, form second-order arcades. Branches extend from the latter, forming arcades of the third and higher orders. There are usually 3 to 5 arcades, the caliber of which decreases as they approach the intestinal wall. It should be noted that in the very initial parts of the jejunum there are only first-order arcades, and as we approach the end of the small intestine, the structure of the vascular arcades becomes more complicated and their number increases.

The last row of arterial arcades, 1-3 cm from the intestinal wall, forms a kind of continuous vessel, from which direct arteries extend to the mesenteric edge of the small intestine. One vessel recta supplies blood to a limited area of the small intestine (Fig. 8.42). In this regard, damage to such vessels for 3-5 cm or more disrupts the blood supply in this area.

Wounds and ruptures of the mesentery within the arcades (at a distance from the intestinal wall), although accompanied by more severe bleeding due to the larger diameter of the arteries, do not lead to disruption of the intestinal blood supply when they are ligated due to good collateral blood supply through the adjacent arcades.

The arcades make it possible to isolate a long loop of the small intestine during various operations on the stomach or esophagus. A long loop is much easier to pull to organs located in the upper floor of the abdominal cavity or even in the mediastinum.

However, it should be borne in mind that even such a powerful collateral network cannot help with embolism (blockage by a detached blood clot) of the superior mesenteric artery. More often than not, this very quickly leads to catastrophic consequences. With a gradual narrowing of the artery lumen due to the growth of an atherosclerotic plaque and the appearance of corresponding symptoms, there is a chance to help the patient by stenting or prosthetics of the superior mesenteric artery.

Educational video of the anatomy of the superior, inferior mesenteric arteries and their branches supplying blood to the intestines

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Superior mesenteric artery

Superior mesenteric artery, a mesenterial superior. Unpaired branch of the abdominal aorta. It begins approximately 1 cm below the celiac trunk, first lies behind the pancreas, then passes in front of the uncinate process. Its branches continue into the mesentery of the small and transverse colon. Rice. A, B.
Inferior pancreaticoduodenal artery pancreaticoduodenalis inferior. It arises at the level of the upper edge of the horizontal part of the duodenum. Its branches lie in front and behind the head of the pancreas. Rice. A. 2a Anterior branch, ramus anterior. Anastomoses with the anterior superior pancreaticoduodenal artery. Rice. IN.
Jejunal arteries, aajejunales. Goes to the jejunum in its mesentery. Rice. A.
Ileal arteries, aa ileales. They approach the ileum between the two layers of its mesentery. Rice. A.
Ileocolic artery, a. ileocolica. In the mesentery of the small intestine it goes down and to the right to the iliocecal angle. Rice. A.
Colon branch, ramus colicus. It goes to the ascending colon. Anastomoses with the right colonic artery. Rice. A.
Anterior cecal artery, a. caecalis (cecalis) anterior. In the cecal fold it approaches the anterior surface of the cecum. Rice. A.
Posterior cecal artery, a. caecalis (cecalis) posterior. It goes behind the final section of the ileum to the posterior surface of the cecum. Rice. A.
Artery of the vermiform appendix, a. appendicularis. It crosses the ileum posteriorly and lies along the free edge of the mesentery of the appendix. The origin of the artery is not constant; it can be double. Rice. A. 9a Ileal branch, ramus ile: alis. It goes to the ileum and anastomoses with one of the small intestinal arteries. Rice. A.
Right colic artery, a. Colica dextra. Anastomoses with the ascending branch of the ileocolic and middle colic arteries. Rice. A. 10a Artery of the right flexure of the colon, aflexura dextra. Rice. A.
Middle colic artery, a. Colica media. Located in the mesentery of the transverse colon. Rice. A. Pa Marginal colic artery, a. marginalis coli []. Anastomosis of the left colon and sigmoid arteries. Rice. B.
The inferior mesenteric artery, and tesenterica inferior. Departs from the abdominal aorta at the level of L3 - L4. It goes to the left and supplies the left third of the transverse colon, descending, sigmoid colon, as well as most of the rectum. Rice. B. 12a Ascending [intermesenteric] artery, a ascendeus. Anastomoses with the left colic and middle colic arteries. Rice. A, B.
Left colic artery, a. Colica sinistra. Retroperitoneally directed to the descending colon. Rice. B.
Sigmoid intestinal arteries, aa. sigmoideae. It goes obliquely down to the wall of the sigmoid colon. Rice. B.
Superior rectal artery, a. rectalis superior. Behind the rectum it enters the small pelvis, where it divides into right and left branches, which, perforating the muscle layer, supply blood to the intestinal mucosa to the anal valves. Rice. B.
The middle adrenal artery, and suprarenalis (adrenalis) media. It arises from the abdominal aorta and supplies blood to the adrenal gland. Rice. IN.
Renal artery, a. renalis. It starts from the aorta at level L 1 and is divided into several branches that go to the gate of the kidney. Rice. B, D. 17a Capsular arteries, aaxapsulares (perirenales). Rice. IN.
Inferior adrenal artery, a. suprarenalis inferior. Participates in the blood supply to the adrenal gland. Rice. IN.
Anterior branch, ramus anterior. Supplies blood to the upper, anterior and lower segments of the kidney. Rice. V, G.
Artery of the upper segment, a. segment superioris. Spreads to the posterior surface of the kidney. Rice. IN.
Artery of the upper anterior segment, a.segmenti anterioris superioris. Rice. IN.
Artery of the lower anterior segment, a segmenti anterioris inferioris. Branch to the anterioinferior segment of the kidney. Rice. IN.
Artery of the lower segment, a. segmenti inferioris. Spreads to the posterior surface of the organ. Rice. IN.
Posterior branch, ramus posterior. It goes to the posterior, largest segment of the kidney. Rice. V, G.
Artery of the posterior segment, a. segmenti posterioris. Branches in the corresponding segment of the kidney. Rice. G.
Ureteral branches, rami ureterici. Branches to the ureter. Rice. IN.

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Visceral branches: superior mesenteric artery

The superior mesenteric artery (a. mesenterica superior) is a large vessel that supplies blood to most of the intestines and the pancreas. The origin of the artery varies within the XII thoracic - II lumbar vertebrae. The distance between the orifices of the celiac trunk and the superior mesenteric artery varies from 0.2 to 2 cm.

Coming from under the lower edge of the pancreas, the artery goes down and to the right and, together with the superior mesenteric vein (to the left of the latter), lies on the anterior surface of the ascending part of the duodenum. Descending along the root of the mesentery of the small intestine towards the ileocecal angle, the artery gives off numerous jejunal and ileal arteries, which pass into the free mesentery. The two right branches of the superior mesenteric artery (ileocolic and right colon), heading to the right part of the colon, together with the veins of the same name, lie retroperitoneally, directly under the peritoneal layer of the bottom of the right sinus (between the parietal peritoneum and Toldt's fascia). Regarding the syntopy of various parts of the trunk of the superior mesenteric artery, it is divided into three sections: I - pancreas, II - pancreas-duodenal, III - mesenteric.

The pancreatic section of the superior mesenteric artery is located between the legs of the diaphragm and, heading anterior to the abdominal aorta, pierces the prerenal fascia and Treitz's fascia.

The pancreatic-duodenal section is located in a venous ring formed from above by the splenic vein, below by the left renal vein, on the right by the superior mesenteric vein, and on the left by the inferior mesenteric vein at the place of its confluence with the splenic vein. This anatomical feature of the location of the second section of the superior mesenteric artery determines the cause of arterio-mesenteric intestinal obstruction due to compression of the ascending part of the duodenum between the aorta at the back and the superior mesenteric artery at the front.

The mesenteric section of the superior mesenteric artery is located in the mesentery of the small intestine.

Variants of the superior mesenteric artery are combined into four groups: I - branching of branches usual for the superior mesenteric artery from the aorta and celiac trunk (absence of the trunk of the superior mesenteric artery), II - doubling of the trunk of the superior mesenteric artery, III - branching of the superior mesenteric artery by a common trunk with the celiac artery, IV - the presence of supernumerary branches extending from the superior mesenteric artery (common hepatic, splenic, gastroduodenal, right gastroepiploic, right gastric, transverse pancreatic, left colon, superior rectal) [Kovanov V.V., Anikina T.I., 1974].

Visceral branches: middle adrenal and renal arteries

Middle adrenal artery (a. supra-renalis media) - a small paired vessel extending from the side wall of the upper aorta, slightly below the origin of the superior mesenteric artery. It goes outward, towards the adrenal gland, crossing transversely the lumbar pedicle of the diaphragm. It may originate from the celiac trunk or from the lumbar arteries.

Renal artery (a. renalis) - paired, powerful short artery. Starts from the lateral wall of the aorta almost at a right angle to it at the level I-II lumbar vertebra. The distance from the origin of the superior mesenteric artery varies within 1-3 cm. The trunk of the renal artery can be divided into three sections: periaortic, middle, perinephric. The right renal artery is slightly longer than the left because the aorta lies to the left of the midline. Heading towards the kidney, the right renal artery is located behind the inferior vena cava and crosses the spine with the thoracic lymphatic duct lying on it. Both renal arteries on the way from the aorta to the renal hilum cross the medial legs of the diaphragm in front. Under certain conditions, variations in the relationship of the renal arteries with the medial crura of the diaphragm can cause the development of renovascular hypertension (abnormal development of the medial crura of the diaphragm, in which the renal artery appears posterior to it). Except

In addition, the abnormal location of the renal artery trunk anterior to the inferior vena cava can lead to congestion in the lower extremities. From both renal arteries, thin inferior suprarenal arteries extend upward and ureteric branches extend downward (Fig. 26).

Rice. 26. Branches of the renal artery. 1 - middle adrenal artery; 2 - inferior adrenal artery; 3 - renal artery; 4 - ureteral branches; 5 - posterior branch; 6 - anterior branch; 7 - artery of the lower segment; 8 - artery of the lower anterior segment; 9 - artery of the upper anterior segment; 10 - artery of the upper segment; 11 - capsular arteries. Quite often (15-35% of cases reported by different authors) accessory renal arteries are found. All their variety can be divided into two groups: arteries entering the hilus of the kidney (accessory hilus) and arteries penetrating the parenchyma outside the hilum, often through the upper or lower pole (additional polar or perforating). The arteries of the first group almost always arise from the aorta and run parallel to the main artery. In addition to the aorta, polar (perforating) arteries can also arise from other sources (common, external or internal iliac, adrenal, lumbar) [Kovanov V.V., Anikina T.I., 1974].

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superior mesenteric artery

Dictionary of terms and concepts on human anatomy. - M.: Higher school. Borisevich V.G. Koveshnikov, O.Yu. Romensky. 1990.

See what “superior mesenteric artery” is in other dictionaries:

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The inferior mesenteric artery (arteria mesenterica inferior) and its branches - The transverse colon and greater omentum are raised upward. The loops of the small intestine are turned to the right. transverse colon; arterial anastomosis (riolan arch); inferior mesenteric vein; inferior mesenteric artery; abdominal aorta; right... ... Atlas of human anatomy

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Endocrine glands (endocrine glands) - Fig. 258. Position of endocrine glands in the human body. Front view. I pituitary gland and pineal gland; 2 paraschitoid glands; 3 thyroid gland; 4 adrenal glands; 5 pancreatic islets; 6 ovary; 7 testicle. Fig. 258. Position of the endocrine glands ... Atlas of Human Anatomy

Digestive system - ensures that the body absorbs the nutrients it needs as a source of energy, as well as for cell renewal and growth. The human digestive apparatus is represented by the digestive tube, large glands of the digestive... ... Atlas of Human Anatomy

HUMAN ANATOMY is a science that studies the structure of the body, individual organs, tissues and their relationships in the body. All living things are characterized by four characteristics: growth, metabolism, irritability and the ability to reproduce themselves. The totality of these characteristics... ... Collier's Encyclopedia

Arteries of the pelvis and lower limb - The common iliac artery (a. iliaca communis) (Fig. 225, 227) is a paired vessel formed through bifurcation (division) of the abdominal aorta. At the level of the sacroiliac joint, each common iliac artery gives ... ... Atlas of Human Anatomy

Aorta - (aorta) (Fig. 201, 213, 215, 223) is the largest arterial vessel in the human body, from which all arteries depart, forming a systemic circulation. It contains the ascending part (pars ascendens aortae), the aortic arch (arcus aortae) ... ... Atlas of Human Anatomy

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1. Superior mesenteric artery, a mesenterial superior. Unpaired branch of the abdominal aorta. It begins approximately 1 cm below the celiac trunk, first lies behind the pancreas, then passes in front of the uncinate process. Its branches continue into the mesentery of the small and transverse colon. Rice. A, B.

2. Inferior pancreaticoduodenal artery pancreaticoduodenalis inferior. It arises at the level of the upper edge of the horizontal part of the duodenum. Its branches lie in front and behind the head of the pancreas. Rice. A. 2a Anterior branch, ramus anterior. Anastomoses with the anterior superior pancreaticoduodenal artery. Rice. IN.

3. Jejunal arteries, aajejunales. Goes to the jejunum in its mesentery. Rice. A.

4. Ileal arteries, aa ileales. They approach the ileum between the two layers of its mesentery. Rice. A.

5. Ileocolic artery, a. ileocolica. In the mesentery of the small intestine it goes down and to the right to the iliocecal angle. Rice. A.

6. Colon branch, ramus colicus. It goes to the ascending colon. Anastomoses with the right colonic artery. Rice. A.

7. Anterior cecal artery, a. caecalis (cecalis) anterior. In the cecal fold it approaches the anterior surface of the cecum. Rice. A.

8. Posterior cecal artery, a. caecalis (cecalis) posterior. It goes behind the final section of the ileum to the posterior surface of the cecum. Rice. A.

9. Artery of the vermiform appendix, a. appendicularis. It crosses the ileum posteriorly and lies along the free edge of the mesentery of the appendix. The origin of the artery is not constant; it can be double. Rice. A. 9a Ileal branch, ramus ile: alis. It goes to the ileum and anastomoses with one of the small intestinal arteries. Rice. A.

10. Right colic artery, a. Colica dextra. Anastomoses with the ascending branch of the ileocolic and middle colic arteries. Rice. A. 10a Artery of the right flexure of the colon, aflexura dextra. Rice. A.

11. Middle colic artery, a. Colica media. Located in the mesentery of the transverse colon. Rice. A. Pa Marginal colic artery, a. marginalis coli []. Anastomosis of the left colon and sigmoid arteries. Rice. B.

12. Inferior mesenteric artery, and tesenterica inferior. Departs from the abdominal aorta at the level of L3 - L4. It goes to the left and supplies the left third of the transverse colon, descending, sigmoid colon, as well as most of the rectum. Rice. B. 12a Ascending [intermesenteric] artery, a ascendeus. Anastomoses with the left colic and middle colic arteries. Rice. A, B.

13. Left colic artery, a. Colica sinistra. Retroperitoneally directed to the descending colon. Rice. B.

14. Sigmoid intestinal arteries, aa. sigmoideae. It goes obliquely down to the wall of the sigmoid colon. Rice. B.

15. Superior rectal artery, a. rectalis superior. Behind the rectum it enters the small pelvis, where it is divided into right and left branches, which, perforating the muscle layer, supply blood to the intestinal mucosa to the anal valves. Rice. B.

16. Middle adrenal artery, and suprarenalis (adrenalis) media. It arises from the abdominal aorta and supplies blood to the adrenal gland. Rice. IN.

17. Renal artery, a. renalis. It starts from the aorta at level L 1 and is divided into several branches that go to the gate of the kidney. Rice. B, D. 17a Capsular arteries, aaxapsulares (perirenales). Rice. IN.

18. Inferior adrenal artery, a. suprarenalis inferior. Participates in the blood supply to the adrenal gland. Rice. IN.

19. Anterior branch, ramus anterior. Supplies blood to the upper, anterior and lower segments of the kidney. Rice. V, G.

20. Artery of the upper segment, a. segment superioris. Spreads to the posterior surface of the kidney. Rice. IN.

21. Artery of the upper anterior segment, a.segmenti anterioris superioris. Rice. IN.

22. Artery of the lower anterior segment, a segmenti anterioris inferioris. Branch to the anterioinferior segment of the kidney. Rice. IN.

23. Artery of the lower segment, a. segmenti inferioris. Spreads to the posterior surface of the organ. Rice. IN.

The abdominal aorta gives off splanchnic, parietal and terminal branches.

Internal branches of the abdominal aorta

1. The celiac trunk (truncus celiacus), 9 mm in diameter, 0.5 - 2 cm long, extends ventrally from the aorta at the level of the XII thoracic vertebra (Fig. 402). Under the base of the celiac trunk is the upper edge of the body of the pancreas, and on the sides of it is the celiac nerve plexus. Behind the parietal layer of the peritoneum, the celiac trunk is divided into 3 arteries: the left gastric, common hepatic and splenic.

402. Branching of the celiac trunk.
1 - truncus celiacus; 2 - a. gastrica sinistra; 3 - a. lienalis; 4 - a. gastroepiploica sinistra; 5 - a. gastroepiploica dextra; 6 - a. gastroduodenalis; 7 - v. portae; 8 - a. hepatica communis; 9 - ductus choledochus; 10 - ductus cysticus; 11 - a. cystica.

a) The left gastric artery (a. gastrica sinistra) initially passes behind the parietal peritoneum at a distance of 2 - 3 cm, goes up and to the left to the place where the esophagus enters the stomach, where it penetrates the thickness of the lesser omentum and, turning 180°, descends along the lesser curvature of the stomach towards the right gastric artery. From the left gastric artery branches extend to the anterior and posterior walls of the body and the cardiac part of the esophagus, anastomosing with the arteries of the esophagus, the right gastric and short gastric arteries. Sometimes the left gastric artery begins from the aorta through a common trunk with the inferior phrenic artery.
b) The common hepatic artery (a. hepatica communis) goes to the right from the celiac trunk, located behind and parallel to the pyloric part of the stomach. It is up to 5 cm long. At the beginning of the duodenum, the common hepatic artery is divided into the gastroduodenal artery (a. gastroduodenalis) and the proper hepatic artery (a. hepatica propria). The right gastric artery (a. gastrica dextra) originates from the latter. The proper hepatic artery is located medial to the common bile duct and at the porta hepatis it divides into right and left branches. The cystic artery (a. cystica) departs from the right branch to the gallbladder. A. gastroduodenalis, penetrating between the pyloric part of the stomach and the head of the pancreas, is divided into two arteries: the superior pancreaticoduodenal (a. pancreaticoduodenal superior) and the right gastroepiploica (a. gastroepiploica dextra). The latter passes in the omentum along the greater curvature of the stomach and anastomoses with the left gastroepiploic artery. A. gastrica dextra is located on the lesser curvature of the stomach and anastomoses with the left gastric artery.
c) The splenic artery (a. lienalis) passes behind the stomach along the upper edge of the pancreas, reaching the hilum of the spleen, where it divides into 3 - 6 branches. From it depart: branches to the pancreas (rr. pancreatici), short gastric arteries (aa. gastricae breves) to the fornix of the stomach, left gastroepiploic artery (a. gastroepiploica sinistra) to the greater curvature of the stomach. The latter anastomoses with the right gastroepiploic artery, which is a branch of a. gastroduodenalis (Fig. 403).

403. Branching diagram of the celiac trunk.

1 - tr. celiacus;
2 - a. gastrica sinistra;
3 - a. lienalis;
4 - a. gastroepiploica sinistra;
5 - a. gastroepiploica dextra;
6 - a. mesenterica superior;
7 - a. gastrica dextra;
8 - a. pancreaticoduodenalis inferior;
9 - a. pancreaticoduodenalis superior;
10 - a. gastroduodenalis;
11 - a. cystica;
12 - a. hepatica propria;
13 - a. hepatica communis.

2. The superior mesenteric artery (a. mesenterica superior) is unpaired, arises from the anterior surface of the aorta at the level of the XII thoracic or I lumbar vertebra. Has a diameter of 10 mm. The initial part of the artery is located behind the head of the pancreas. The second section of the artery is surrounded by veins: above - splenic, below - left renal, on the left - inferior mesenteric, on the right - superior mesenteric. The artery and veins are located between the pancreas and the ascending part of the duodenum. At its lower edge at the level of the II lumbar vertebra, the artery enters the root of the mesentery of the small intestine (Fig. 404).

404. Superior mesenteric artery.
1 - omentum majus; 2 - anastomosis between a. colica media and a. colica sinistra: 3 - a. colica sinistra; 4 - a. mesenterica superior; 5 - aa. jejunales; 6 - aa. appendiculares: 7 - aa. ilei; 8 - a. ileocolica; 9 - a. Colica dextra; 10 - a. Colica media.

The superior mesenteric artery gives off the following branches: the inferior pancreaticoduodenal artery (a. pancreaticoduodenalis inferior), anastomosing with the superior artery of the same name, 18-24 intestinal arteries (aa. jejunales et ilei), running in the mesentery to the loops of the jejunum and ileum, forming their plexuses and networks (Fig. 405), the ileocolic artery (a. iliocolica) - to the cecum; it gives a branch to the vermiform appendix (a. appendicularis), which is located in the mesentery of the appendix. From the superior mesenteric artery to the ascending colon depart the right colic artery (a. colica dextra), the middle colic artery (a. colica media), which runs in the thickness of the mesocolon. The listed arteries in the mesentery of the colon anastomose with each other.

405. Network of blood capillaries in the mucous membrane of the small intestine.

3. The inferior mesenteric artery (a. mesenterica inferior) is unpaired, like the previous one, starts from the anterior wall of the abdominal aorta at the level of the III lumbar vertebra. The main trunk of the artery and its branches are located behind the parietal layer of the peritoneum and supply blood to the descending, sigmoid and rectum. The artery is divided into the following 3 large arteries: the left colon (a. colica sinistra) - to the descending colon, the sigmoid arteries (aa. sigmoideae) - to the sigmoid colon, the upper rectalis (a. rectalis superior) - to the rectum (Fig. 406 ).

406. Inferior mesenteric artery.
1 - a. mesenterica inferior; 2 - aorta abdominalis; 3 - aa. sigmoideae; 4 - aa. rectales superiores; 5 - a. iliaca communis dextra; 6 - mesenterium; 7 - a. colica media; 8 - a. Colica sinistra.

All arteries approaching the colon anastomose with each other. The anastomosis between the middle and left colonic arteries is especially important, since they represent branches of various arterial sources.

4. The middle adrenal artery (a. suprarenalis media) is a pair, branches from the lateral surface of the aorta at the level of the lower edge of the first lumbar vertebra, sometimes from the celiac trunk or from the lumbar arteries. At the gate of the adrenal gland it is divided into 5-6 branches. In the adrenal capsule they anastomose with the branches of the superior and inferior adrenal arteries.

5. The renal artery (a. renalis) is steamy, with a diameter of 7-8 mm. The right renal artery is 0.5 - 0.8 cm longer than the left. In the renal sinus, the artery divides into 4-5 segmental arteries, which form interlobar arteries. At the border of the cortex they are connected to each other by the arcuate arteries. The interlobular arteries located in the cortex begin from the arcuate arteries. From the interlobular arteries originate the afferent arterioles (vas efferens), which pass into the vascular glomeruli. From the glomerulus of the kidney, an efferent arteriole (vas efferens) is formed, which breaks up into capillaries. Capillaries entwine the nephron of the kidney. At the gate of the kidney, the inferior adrenal artery (a. suprarenalis inferior) departs from the renal artery, supplying blood to the adrenal gland and the fatty capsule of the kidney.

6. Testicular (ovarian) artery (a. testicularis s. a. ovarica) is a pair, branches from the aorta at the level of the II lumbar vertebra behind the root of the mesentery of the small intestine. Branches extend from it in the upper part to supply blood to the fatty membrane of the kidney and ureter. Supplies blood to the corresponding sex glands.

Arteriograms of the renal vessels. The contrast agent is injected through a catheter into the aorta or directly into the renal artery. Such images are usually performed if sclerosis, narrowing or anomaly of the kidney is suspected (Fig. 407).

407. Selective arteriogram of the right kidney. 1 - catheter; 2 - right renal artery; 3 - intrarenal arterial branches.

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Treatment of acute disorders of mesenteric circulation in the vast majority of cases involves emergency surgery, which should be undertaken as soon as the diagnosis is made or there is a reasonable suspicion of this disease. Only active surgical tactics provide a real chance of saving the lives of patients. Conservative treatment methods should be used in combination with surgical ones, complementing, but in no case replacing them. Therapeutic and resuscitation measures carried out in situations where the development of non-occlusive disorders of mesenteric blood flow is possible are effective only until clinical symptoms appear in the abdominal organs and can only be considered as preventive measures.

Surgical intervention should solve the following problems:
1) restoration of mesenteric blood flow;
2) removal of non-viable areas of the intestine;
3) fight against peritonitis.

The nature and extent of surgical intervention in each specific case are determined by a number of factors: the mechanism of mesenteric circulation disturbance, the stage of the disease, the location and extent of the affected areas of the intestine, the general condition of the patient, surgical equipment and the experience of the surgeon. All types of operations come down to three approaches:
1) vascular interventions;
2) intestinal resection;
3) combinations of these methods.

It is obvious that vascular operations are the most appropriate. As a rule, we are talking about intervention on the superior mesenteric artery. Restoring blood flow through the mesenteric arteries within the first 6 hours from the moment of occlusion usually leads to the prevention of intestinal gangrene and restoration of its functions. However, even when the patient is admitted at a later date, when irreversible changes occur in a more or less extended section of the intestine, in addition to its removal, surgery on the mesenteric vessels may be necessary to restore blood flow in its still viable sections. That is why in most cases it is necessary to combine vascular operations and resection interventions.

The main stages of surgery include:

surgical approach;
inspection of the intestine and assessment of its viability;
revision of the main mesenteric vessels;
restoration of mesenteric blood flow;
intestinal resection according to indications;
deciding on the timing of anastomosis; sanitation and drainage of the abdominal cavity.

Surgical approach should provide the possibility of inspection of the entire intestine, the main vessels of the mesentery, and sanitation of all parts of the abdominal cavity. A wide median laparotomy seems optimal.

Intestinal audit necessarily precedes active surgical actions. The subsequent actions of the surgeon depend on the correct determination of the nature, localization, prevalence and severity of intestinal damage. The detection of total gangrene of the small intestine forces us to limit ourselves to a trial laparotomy, since intestinal transplantation, one of the most complex operations in modern medicine, despite the progress achieved in recent years, is not yet the province of emergency surgery.

Assessing intestinal viability is based on known clinical criteria: coloring of the intestinal wall, determination of peristalsis and pulsation of the mesenteric arteries. This assessment in cases of obvious necrosis is quite simple. Determining the viability of an ischemic bowel is much more difficult. Mesenteric circulation disorders are characterized by a “mosaic pattern” of ischemic disorders: neighboring areas of the intestine may be in different circulatory conditions. Therefore, after the vascular stage of surgery, a repeated thorough examination of the intestine is necessary. In some cases, it is advisable to perform it during relaparotomy one day after the first operation.

Revision of the main mesenteric vessels- the most important stage of surgical intervention. The inspection of the arteries begins with inspection and palpation of the vessels near the intestine. Normally, pulsation is clearly visible visually. If mesenteric blood flow is impaired, pulsation along the edge of the intestine disappears or becomes weak. It is also difficult to detect it due to the developing edema of the mesentery and intestinal wall. It is convenient to determine pulsation along the mesenteric edge by clasping the intestine with the thumb, index and middle fingers of both hands.

The pulsation of the trunk of the superior mesenteric artery can be determined using two different techniques (Fig. 50-2).

Rice. 50-2. Methods for determining the pulsation of the superior mesenteric artery.

First is as follows: under the mesentery of the small intestine, the thumb of the right hand, feeling the pulsation of the aorta, is moved as high as possible to the origin of the superior mesenteric artery. With the index finger, the root of the mesentery of the small intestine is grasped from above immediately to the right of the duodenum-jejunal flexure.

Second technique - the right hand is brought under the first loop of the jejunum and its mesentery (with the thumb located above the intestine) and slightly pulled down. Using the fingers of the left hand, a cord is found in the mesentery, in which the superior mesenteric artery is palpated. Along its trunk, with a lean mesentery, an embolus can sometimes be palpated. Indirect signs of thrombosis are pronounced atherosclerosis of the aorta and the presence of plaque at the mouth of the artery. By moving the small intestine and its mesentery to the right, you can determine the pulsation of the aorta and inferior mesenteric artery.

In doubtful cases (with mesenteric edema, systemic hypotension, severe obesity), it is advisable to isolate the trunks of the mesenteric arteries and conduct their audit. This is also necessary for performing interventions on them aimed at restoring blood circulation in the intestines.

Exposure of the superior mesenteric artery can be done from two approaches: anterior and posterior (Fig. 50-3).

Rice. 50-3. Exposure of the superior mesenteric artery: (1 - superior mesenteric artery; 2 - middle colic artery; 3 - ileocolic artery; 4 - aorta; 5 - inferior vena cava; 6 - left renal vein; 7 - inferior mesenteric artery): a - anterior approach; b - rear access.

Anterior approach simpler and is usually used for embolism. To do this, the transverse colon is brought into the wound and its mesentery is stretched. The mesentery of the small intestine is straightened, the intestinal loops are moved to the left and downwards. The initial section of the mesentery of the jejunum is also stretched. The posterior layer of the parietal peritoneum is dissected longitudinally from the ligament of Treitz along the line connecting it to the ileocecal angle. In case of fatty mesentery or its edema, you can use the middle colic artery as a guide, exposing it towards the mouth, moving gradually towards the main arterial trunk. Large branches of the superior mesenteric vein lying above the trunk of the artery are mobilized, displaced, but in no case crossed. The trunk and branches of the superior mesenteric artery are exposed for 6-8 cm. With an anterior approach, the first 2-3 cm of the trunk and its mouth, covered with rather dense fibrous tissue, are usually not exposed. The superior mesenteric vein is exposed in a similar way.

With posterior access(to the left in relation to the root of the mesentery of the small intestine) the intestinal loops are moved to the right and down. The ligament of Treitz is stretched and dissected, and the duodenojejunal flexure is mobilized. Next, the parietal peritoneum is incised above the aorta so as to create a right-curved incision. It is better to dissect the tissue from below: the aorta is exposed, then the left renal vein, which is mobilized and retracted downwards. Above the vein, the mouth of the superior mesenteric artery is exposed. This access is advisable to use in case of thrombosis, since the atherosclerotic plaque is often located in the area of the artery mouth. To perform possible vascular reconstruction, it is necessary to isolate the area of the aorta above and below the orifice.

For the purpose of highlighting inferior mesenteric artery extend the longitudinal section of the peritoneum downwards along the aorta. Along its left lateral contour the trunk of the artery is found.

Restoration of mesenteric blood flow produced in various ways depending on the nature of the vascular occlusion. Embolectomy from the superior mesenteric artery is usually performed from an anterior approach (Fig. 50-4).

Rice. 50-4. Scheme of indirect embolectomy from the superior mesenteric artery: a, b - stages of the operation; 1 - middle colon artery.

A transverse arteriotomy is made 5-7 mm above the mouth of the middle colic artery so that its catheter revision can be carried out along with the ileocolic and at least one of the intestinal branches. Embolectomy is performed using a Fogarty balloon catheter. The arteriotomy is sutured with separate synthetic sutures on an atraumatic needle. To prevent vasospasm, novocaine blockade of the mesenteric root is performed. Effective restoration of blood flow is judged by the appearance of pulsation in the trunk and branches of the superior mesenteric artery, restoration of the pink color of the intestines and peristalsis.

Vascular operations for arterial thrombosis are technically more difficult, they have to be performed when the condition of the distal mesenteric bed is unknown and they give worse results. Due to the predominant localization of thrombosis in the first segment of the trunk of the superior mesenteric artery, a posterior approach to the vessel is indicated.

Depending on the clinical situation, perform thrombinthymectomy followed by sewing in an autovenous or synthetic patch (Fig. 50-5), bypass surgery, reimplantation of the artery into the aorta, replacement of the superior mesenteric artery.

Rice. 50-5. Scheme of thrombinthymectomy from the superior mesenteric artery.

From a technical point of view, thrombinthymectomy is the simplest. To prevent rethrombosis, it is advisable to make a longitudinal incision of the artery longer than the area of the intima being removed, and be sure to suture the distal edge of the intima with U-shaped sutures.

Bypass operations are promising when the trunk of the superior mesenteric artery is anastomosed with the splenic artery, right common iliac artery or aorta. Rethrombosis occurs less frequently after these interventions. Prosthesis of the superior mesenteric artery is indicated when it has thrombosis over a significant extent. The prosthesis can be sewn in after resection of the artery in the first segment, between the aorta and the distal end of the artery, and also connect the mesenteric bed to the right common iliac artery.

Thrombectomy from the superior mesenteric vein is aimed mainly at preventing portal vein thrombosis. The trunk of the superior mesenteric vein below the mesentery of the transverse colon is exposed, a transverse phlebotomy is performed, and thrombotic masses are removed using a Fogarty catheter. In case of severe swelling of the mesentery, when it is difficult to expose the trunk of the superior mesenteric vein, thrombectomy can be performed through a large intestinal branch.

Bowel resection in case of mesenteric circulation disorders, both independent intervention and in combination with vascular operations can be used. As independent operation resection is indicated for thrombosis and embolism distal branches superior or inferior mesenteric arteries, limited in extent venous thrombosis, decompensated non-occlusal disorders blood flow In these cases, the extent of intestinal damage is usually small, so after resection there are usually no digestive disorders.

At the same time, intestinal resection in case of occlusion of the first segment of the superior mesenteric artery as an independent operation is futile, and if total necrosis has not yet occurred in accordance with the level of occlusion, it should always be combined with vascular surgery.

The rules for performing intestinal resection differ depending on whether it is performed as an independent operation or in conjunction with vascular intervention. In case of occlusion of the branches of the mesenteric arteries, when intervention is not performed on them, one should retreat from the visible boundaries of the non-viable section of the intestine by 20-25 cm in each direction, taking into account the advancing dynamics of necrotic changes in the internal layers of the intestine. When transecting the mesentery, it is necessary to ensure that, in accordance with the level of resection, there are no thrombosed vessels in it, and that the transected vessels bleed well. If resection is performed together with vascular surgery, then after restoration of blood circulation only areas of clearly non-viable intestine are removed; the resection border may be closer to necrotic tissues. In such a situation, the tactic of delayed anastomosis during relaparotomy is especially justified.

The predominance of high occlusions and late timing of surgical interventions in acute disorders of the mesenteric circulation quite often determine the performance of subtotal resections of the small intestine. Due to the wide range of length of the small intestine, the length of the removed segment itself is not prognostically decisive. Much more important is the size of the remaining intestine. The critical value in the majority of initially relatively healthy patients is about 1 m of the small intestine.

When performing resection for infarction, it is necessary to follow some technical rules. Along with the intestine affected by the infarction, it is necessary to remove the altered mesentery with thrombosed vessels, so it is not crossed along the edge of the intestine, but at a significant distance from it. In case of thrombosis of the branches of the superior mesenteric artery or vein, after dissection of the peritoneal layer 5-6 cm from the edge of the intestine, the vessels are isolated, crossed and ligated. For extensive resections with intersection of the trunk of the superior mesenteric artery or vein, a wedge-shaped resection of the mesentery is performed. The trunk of the superior mesenteric artery is divided in such a way as not to leave a large “blind” stump next to the outgoing pulsating branch.

After resection, within the limits of reliably viable tissue, an end-to-end anastomosis is performed according to one of the generally accepted methods. If there is a significant discrepancy between the ends of the resected intestine, a side-to-side anastomosis is formed.

Delayed anastomosis is often the most appropriate solution. The basis for such tactics are doubts about the exact determination of intestinal viability and the extremely difficult condition of the patient during surgery. In such a situation, the operation is completed by suturing the stumps of the resected intestine and active nasointestinal drainage of the afferent small intestine. After the patient’s condition has been stabilized against the background of intensive therapy (usually every other day), during relaparotomy the viability of the intestine in the resection area is finally assessed; if necessary, reresection is performed and only after that an interintestinal anastomosis is performed.

When signs of non-viability of the cecum and ascending colon are detected, it is necessary to perform a right hemicolectomy along with resection of the small intestine. In this case, the operation is completed with ileotransversostomy.

Necrotic changes found in the left half of the colon require resection of the sigmoid colon (for thrombosis of the branches of the inferior mesenteric artery or non-occlusive disturbance of mesenteric blood flow) or left-sided hemicolectomy (for occlusion of the trunk of the inferior mesenteric artery). Due to the serious condition of the patients and the high risk of failure of the primary colonic anastomosis, the operation, as a rule, should be completed with a colostomy.

If intestinal gangrene is detected, it is advisable to use the following procedure for surgical intervention. First, resection of clearly necrotic intestinal loops is performed with wedge-shaped excision of the mesentery, leaving areas of questionable viability. In this case, surgery on the mesenteric arteries is delayed by 15-20 minutes, but the delay is compensated by better conditions for further surgery, since swollen, non-viable intestinal loops make intervention on the mesenteric vessels difficult. In addition, this procedure prevents a sharp increase in endotoxemia after restoration of blood flow through the vessels of the mesentery, its possible phlegmon and to a certain extent stops infection of the abdominal cavity and the development of purulent peritonitis. The stumps of the resected intestine are sutured with a UKL-type apparatus and placed in the abdominal cavity. Then intervention is performed on the vessels. After eliminating the arterial occlusion, it is possible to finally assess the viability of the remaining intestinal loops, decide on the need for additional intestinal resection and the possibility of anastomosis.

It is advisable to complete the intervention on the intestines with nasointestinal intubation, which is necessary to combat postoperative paresis and endotoxicosis. Sanitation and drainage of the abdominal cavity is performed in the same way as for other forms of secondary peritonitis.

In the postoperative period, intensive care includes measures aimed at improving systemic and tissue circulation, which is especially important for the state of the intestinal microvasculature, maintaining adequate gas exchange and oxygenation, correcting metabolic disorders, combating toxemia and bacteremia. It must be taken into account that resection of non-viable intestine does not eliminate severe systemic disorders, which may even worsen in the immediate postoperative period.

Low resistance of patients predisposes to the development of general surgical complications (abdominal surgical sepsis, pneumonia, pulmonary embolism). These complications can be prevented by complex intensive therapy. At the same time, any conservative measures in case of relapse or progression of vascular occlusion will be useless. The main diagnostic efforts in the postoperative period should be aimed at identifying ongoing intestinal gangrene and peritonitis.

In patients with ongoing gangrene of the intestine persistent leukocytosis and a pronounced band shift with a tendency to increase are noted, and the ESR increases. The development of hyperbilirubinemia and the progressive accumulation of nitrogenous waste in the blood are characteristic signs of ongoing intestinal gangrene, which indicate deep toxic damage to the liver and kidney parenchyma. Urine output progressively decreases to the point of anuria, despite large amounts of fluid administered and significant doses of diuretics. Urine examination reveals the development of toxic nephrosis, manifested in persistent and increasing proteinuria, cylindruria and microhematuria. Reasonable suspicions of ongoing intestinal gangrene serve as indications for emergency relaparotomy.

Early targeted (programmed) relaparotomy performed to monitor the condition of the abdominal cavity or to perform a delayed anastomosis. The need for repeated revision of the abdominal cavity arises in cases where, after revascularization, signs of questionable intestinal viability (swelling, cyanosis of the intestine, weakened peristalsis and pulsation of the arteries along the mesenteric edge) persist throughout the entire intestine (especially the small intestine) or on the remaining small part of it after extensive resection.

Signs of questionable viability usually disappear within 12-24 hours, or obvious gangrene of the intestine develops, and in operable cases, during programmed relaparotomy, limited areas of the affected intestine can be removed without waiting for the development of widespread peritonitis and intoxication. The time for relaparotomy is from 24 to 48 hours after the initial operation. Repeated intervention to a certain extent aggravates the patient's condition. At the same time, this is an effective way to save a significant proportion of patients with impaired mesenteric blood flow.

B.C. Savelyev, V.V. Andriyashkin